Healthcare Provider Details

I. General information

NPI: 1831131234
Provider Name (Legal Business Name): SANFORD MEDICAL CENTER FARGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 11/29/2022
Certification Date: 11/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 4TH ST NW
MAHNOMEN MN
56557-4208
US

IV. Provider business mailing address

PO BOX 2168
FARGO ND
58107-2168
US

V. Phone/Fax

Practice location:
  • Phone: 218-935-2514
  • Fax: 218-935-2720
Mailing address:
  • Phone: 701-234-2119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TONY LEE MORRISON
Title or Position: VICE PRESIDENT, REVENUE CYCLE
Credential:
Phone: 605-328-8380